Malako et al.

BMC Nutrition (2019) 5:3

https://doi.org/10.1186/s40795-018-0268-1

RESEARCH ARTICLE Open Access

Stunting and anemia among children 6–23

months old in Damot Sore district,
Southern Ethiopia
Bereket Geze Malako1*, Benedict Oppong Asamoah2, Minyahil Tadesse3, Robel Hussen4 and Meklit Tesfaye Gebre5

Abstract
Background: Stunting and anemia are long-standing public health challenges which adversely affects the cognitive
development and physical wellbeing of children in low income settings. The aim of this study was to assess the
prevalence and associated factors of stunting and anemia among 6–23 months old children in Damot Sore District,
Southern Ethiopia.
Methods: Cross-sectional survey was conducted among 477 children aged 6–23 months, which were living in Damot
Sore District, in April 2017. A multistage sampling technique was used. Villages were randomly selected and systematic
random sampling method was used to select study participants. Data on socio-demographic, anthropometric, dietary,
blood samples for hemoglobin were collected. Data were entered into EPI Data V. 3.1 and exported into SPSS Version
21.0 for analysis. A principal component analysis (PCA) was done to generate wealth score of households. Binary logistic
regression model was used to identify factors associated with the outcome variables (stunting and anemia) separately,
those variables having less than a p-value of 0.25 were chosen as candidate for multivariable analyses and
finally multivariable logistic regression model was used to identify independent variables of each outcomes,
with statistical significance set at p < 0.05 (95% confidence interval (CI)).
Results: Out of 477 children studied, 31.7% were stunted and 52% were anemic. In the multivariable analyses,
the number of under five children within a household (AOR = 4.18, 95% CI: 2.65–6.57), drinking water from unsafe source
(AOR = 4.08, 95% CI: 1.33–12.54) and anemia (AOR = 3.13, 95% CI 2.00–4.92) were factors significantly associated
with stunting. On the other hand, independent variables of anemia were early initiation of complementary feeding
(AOR = 2.96, 95% CI: 1.23–4.85), poor dietary diversity (AOR = 2.95, 95% CI: 1.78–4.91), poor breast feeding practice
(AOR = 2.94, 95% CI: 1.63–5.32) and stunting (AOR = 3.65, 95% CI: 2.15–6.19).
Conclusion: This study revealed higher level of stunting and anemia among children aged 6–23 months than WHO
(world health organization) criteria of public health importance. Sustainable promotion of diversified diet, optimal
complementary feeding, optimal and complementary breast feeding practices, improving sanitation infrastructure are
measures needed to tackle these severe public health challenges.
Keywords: Stunting, Anemia, Southern Ethiopia

* Correspondence: [email protected]
1
World Vision Ethiopia, Jimma area cluster office, Gewata area development
program, Jimma, Ethiopia
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Malako et al. BMC Nutrition (2019) 5:3 Page 2 of 11

Background of Damot Sore District, situated in Southern Nation

Significances of early life experiences to subsequent health Nationalities and Peoples Region (SNNPR), which is 326
outcomes are main public health concerns and increas- km from the capital city of Ethiopia. All children in the
ingly gaining attention in the scientific literature [1]. Early aforementioned age group who stayed in the study area
nutritional malignancies such as stunting and anemia have during the time of the interview were qualified to take
been suggested to cause irreversible health effects of later part in the study.
life courses such as acute and chronic diseases, non-com-
municable diseases, cognitive development and economic
Sample size and sampling procedure
productivity of individuals and the society [1, 2].
A formula for estimation of single population proportion
Anemia (Hb < 110 g/L), which could originate from
was used to calculate the sample size. The following cri-
low consumption or absorption of the diet or blood loss
terions were applied to estimation of the sample size;
and inability to absorb nutrients as a result of infection
95% confidence level, 5% error of margin, and 66.6%
from intestinal worms is believed to be highly prevalent
prevalence of anemia among children aged 6–23 months
during infancy. One fourth of the global population is
old – taken from a previous study in a rural area in
affected by anemia and about 42.6% of them are children
northern Ethiopia [8]. The estimated sample size was
[2]. Various surveys carried out in resource limited settings
then adjusted for a non-response rate of 5% and multi-
revealed that the incidence of stunting is at its highest point
plied by the design effect of 1.5 to obtain a final estimate
in children of the age group from 6 to 23 months, because
of 498, the sample size used for this study.
within this period children have a greater demand for
Study participants were selected by a multi – stage
macro and micronutrients which are vital for child growth.
sampling technique. From a total of 20 rural villages, 6
However, inadequate access to and affordability of quality
were randomly selected using a lottery method.
and sufficient complementary foods, frequent disease epi-
Sampled number of children per village were propor-
sodes, poor sanitation and hygiene practice have been iden-
tionally allocated based on their number of households.
tified as the main causes of malnutrition [2–5].
Finally, using family folder which is found in community
Anemia might occur at any time and at all stages of
health information system (CHIS) of village health posts
the lifespan, but children are the most at risk segment of
as a sampling frame, households with children 6–23
the population in developing countries, and sub-Saharan
months old were selected by simple random sampling
Africa bears the highest burden of anemia [3].
method. For a household that have twins or more than
Children aged 6 to 23 months have high iron require-
one child resident there, one of them was selected by
ments as they are believed to show extremely rapid growth
using lottery method. In case of absence of an eligible
pattern during this period. Trends in Ethiopia indicates
child in a given household, a substitution was made by a
that, the magnitude of anemia among 6–23 months old
child in the next household. Children with physical deform-
children increased over 10% between 2011 and 2016 [4, 5].
ities of limbs, spine, suffering from diseases and have men-
According to the Ethiopian Demographic Health Survey
tal defects were excluded. In addition to this, children who
(EDHS) key indicators report of 2016, 38% of children
had received blood transfusion and anti helmenthiasis prior
below five years of age were stunted nationally, and 38.6%
(two months) to data collection were excluded.
of under-five children were stunted also in Southern
Nations Nationalities and Peoples Region (SNNPR); this
shows that there is chronic severity and burden of malnu- Data collection
trition in the country’s every corner [5]. A study conducted Data were collected using the questionnaire adopted
in Kemba Woreda of Southern Ethiopia also revealed that from previous studies [4, 9] and pre-tested before the
18.7% of children were stunted [6]. Comparisons of two start of this study. The questionnaire was first prepared
agro-ecological areas in northern and eastern part of in English language and then translated to Amharic lan-
Ethiopia indicated that 36.2 and 42.6% of children aged guage. Prior to collection of data, the purpose of this
6–23 months old were stunted, respectively [7]. study was explained to the study units; their consent to
Therefore, this study determined the prevalence and participate was sought and was also informed that their
predictors of stunting and anemia among children aged participation in the study was totally voluntary.
6–23 months old and associated factors in Damot Sore The response from the mother/caregiver was recorded
District, Southern Ethiopia. after the data collectors read out the questions loud.
Date of interview and date of birth was used to calculate
Methods age of the child, because the year of birth is inaccurately
Study area and setting announced oftentimes. The nutritional status for all
Community based cross-sectional survey was carried out children aged 6–23 months old was assessed by taking
among 6–23 months old children residing in 6 villages Anthropometric measurements.
Malako et al. BMC Nutrition (2019) 5:3 Page 3 of 11

Data collectors and measurements checked for household wealth. Data cleaning were done
Anthropometric data for this study was collected by six and outliers were identified and managed properly before
skilled and trained data collectors who administered the the analysis.
questionnaires. Two supervisors closely supervised the
process of data collection. Nutritional status was assessed Data management
by taking anthropometric body measurements of the The data management were done by using three statistical
children. Length of a child was measured in a recumbent softwares. During the data collection, completeness and
position to the nearest 0.1 cm by using a portable board uniformity of the data were checked daily before entry.
provided by UNICEF (United Nations Children’s Fund) The data were first entered into EpiData V.3.1 statistical
with an upright movable wooden base. Anthropometric software for coding. Afterwards the data were transported
measurements were converted to z-scores of indices using into the software WHO Anthro, where length-for-age
WHO Anthro software [10]. Z-scores were computed and further checks done to
ensure that flags resulting from wrongly entered data were
Laboratory investigations corrected. After the initial cleaning, all the z-score values
Hemoglobin count and malaria status of children were which remained as irregular were cleaned from the file
investigated. Hemoglobin was measured from capillary and excluded from further analyses. The cleaned file was
blood by aseptically collecting blood sample from the then exported to SPSS version 21.0 for further analyses.
middle finger of study participants, then the analysis
have been done by using Automated HemoCue analyser Statistical analyses
(HEMOCUE Hb 301, HEMOCUE AB, ANGELHOLM Bivariate and multivariable logistic regression was used
SWEDEN) machines and the results were immediately to examine the association between stunting, anemia
recorded in the field in terms of g/dl. After adjusting the and the explanatory variables. From the binary regres-
hemoglobin concentration for changes in the altitude sion models, independent variables which were associ-
and smoking individual within a household, the results ated with the outcome at p-value less than 0.25 were
were categorized based on the WHO cut off point, which selected as candidate for inclusion in the multivariable
categorizes a child as anemic if the hemoglobin count is logistic regression models. Statistical significance was set
less than 11.0 g/dl [11]. Malaria test was done using rapid at p < 0.05 and 95% confidence interval.
diagnostic test (RDT) kit, which was commonly used to
assess the status of malaria in the community [12]. Blood Operational definition
test for malaria was collected by finger puncture and the Stunting: is defined as length-for-age Z-scores below
result was recorded as positive or negative with regards to minus two <− 2 Z score or Standard deviation of the refer-
species specification. ence population of World Health Organization (WHO)
Multicentre Growth Study. Severe stunting is defined as
Data quality control LAZ scores below minus three <− 3 Z score or Standard
Three day training was given for data collectors about deviation of the reference population of WHO Multicentre
study objective, interview techniques, anthropometric Growth Study [10].
measurements and ethical issues during data collection. Anemia: A child is considered to be anemic if the
Rapid diagnostic malaria test results were compared with hemoglobin count is less than 11.0 g/dl against the WHO
blood film result by microscope. Standard operating proce- reference range [11].
dures and manufacturer’s instructions were strictly followed Poor DDS: dietary diversity of less than 4 food categories.
starting from sample collection up to result reporting for Good DDS: dietary diversity of more than or equal to
laboratory activities. 4 food categories.
The questionnaire was pre-tested on similar setting Poor breast feeding practice: failed to breast for at
outside the study area before the collection of actual least 8 times per day or inappropriate baby position or
data. The principal investigator carefully monitored the switching to the next breast without finishing.
data collection process. Good breast feeding practice: breast feed for more
Quality of the measurements were ensured by maintain- than or equal to 8 times a day or appropriate baby pos-
ing consistency of anthropometric measurement, data col- ition or switching to the next breast after finishing one.
lectors were tested using ENA for SMART software before
starting data collection. Results
Standardization: all children were measured without Socio-demographic characteristics of children and mothers
any shoes and clothes were taken off. From a total of 498 children participated in the study,
Multicollinearity for independent predictors of stunting 477 children were involved in the study yielding a re-
and anemia were checked and Crombach’s alpha was sponse rate of 95.78%. Twenty-one 21(4.22%) of sampled
Malako et al. BMC Nutrition (2019) 5:3 Page 4 of 11

Table 1 Child and parents related characteristics among children aged 6–23 months in Damot Sore District, Southern Ethiopia, from
March to April 2017
Characteristics Categories Frequency (N = 485) Percent (%)
Sex of the child Male 243 50.9
Female 234 49.1
Age of the mother 15–24 years 84 17.6
25–34 years 246 55.3
35–49 years 129 27.0
Age of the child 6–11 months 190 39.8
12–17 months 160 33.5
18–23 months 127 26.6
Educational status of mother No formal education 307 64.4
Formal education 170 35.6
Educational status of father No formal education 238 49.9
Formal education 236 49.5
Mother’s occupation Unemployed 459 96.2
Government/private employee 18 3.8
Father’s occupation Unemployed 454 95.2
Government/private employee 19 4
Total number of family size within households Less than or equal to 5 219 45.9
Greater than 5 258 54.1
Number of under five children within household More than one child 240 50.3
One child 237 49.7
Wealth Low 201 42.1
Middle 72 15.1
High 204 42.8
Introduction time of complementary feeding Earlier than 6 months 223 46.8
Just at 6 months 254 53.2
Breast feeding practice Poor 113 23.7
Good 331 69.4
Never breast feed at all 33 6.9
Source of drinking water Piped inside compound 36 7.5
Public 351 73.6
Protected well/spring 90 18.9
Toilet No facility/bush/field 12 2.5
Have latrine 465 97.5
Utilization of Insecticide Treated Net (ITN) Not appropriately 45 9.4
Appropriately 404 84.7
Never had ITN at all 28 5.9
Having diarrhoea No 313 65.8
Yes 163 34.2
Having Malaria Yes 21 4.4
No 456 95.6
Having low dietary diversity score Yes 313 65.6
No 164 34.4
Malako et al. BMC Nutrition (2019) 5:3 Page 5 of 11

children were dropped from the analysis due to the in- individual within a household based on WHO Hb adjusting
completeness of outcome variables. Mean age of children measurements. In bivariate analysis as shown in Table 3,
and mothers were 13.69 (±5.41) months and 30.11 (±5.78) age of mothers, age of the children, mothers educational
years, respectively. As shown in Table 1 among the total status, fathers occupation, number of under five children
households surveyed, 258 (54.1%) has a total family size within household, introduction time of complementary
greater than five while half of them has more than one feeding, breast feeding practice of mothers, source of
under five children. Two hundred and twenty-three drinking water, toilet, dietary diversity score, growth moni-
(46.8%) mothers introduce complementary feeding in any toring and promotion service utilization and stunting were
other months than just at six months (Table). associated with anemia (Table 3).

Prevalence of stunting among children

The burden of stunting among the study units was 31.7% Independent variables associated with stunting after
and the mean (±SD) stunting (LAZ) of the children was − adjusting for other variables
0.92 (±1.31). As demonstrated in Fig. 1, Z-score curves Source of drinking water, status of anemia, age of the
were shifted to left of the WHO growth reference curve, child, age of the mother, wealth, availability of toilet,
which shows stunting, is prevalent in the study area (Fig. 1). number of children under five years of age living in
In bivariate analysis as shown in Table 2, age of mothers, a household, occupation of mother, were found to be
age of the children, mothers occupation, number of under statistically significant in bivariate analysis. In a mul-
five children within household, wealth, source of drinking tivariable logistic regression analysis which was as
water, toilet, dietary diversity score and anemia were asso- shown on Table 4, the number of under five children
ciated with stunting (Table 2). within household (AOR = 4.18, 95% CI: 2.65–6.57),
drinking water from unsafe source (AOR = 4.08, 95%
Prevalence of anemia CI: 1.3312.54) and anemia (AOR = 3.13, 95% CI 2.00–
This study revealed that the magnitude of anemia was 4.92) were factors significantly associated with stunt-
found to be 52% after adjusting for altitude and smoking ing (Table 4).

Fig. 1 LAZ-scores compared to WHO growth standards in Damot Sore district, Southern Ethiopia, from March to April 2017
Malako et al. BMC Nutrition (2019) 5:3 Page 6 of 11

Table 2 Bivariate analysis that shows independent variables of stunting among children in Damot Sore District, Southern Ethiopia,
from March to April 2017
Stunting status COR (95% C.I.) P
Stunted Not stunted
Characteristics Categories
Sex of the children Male 72 171 0.83(0.56–1.22) 0.33
Female 79 155 1
Age of mothers 15–24 years 35 49 1.41(0.86–2.33) 0.17*
25-34 years 70 194 1.49(0.89–2.93) 0.13*
35-49 years 46 83 1
Age of the children 6–11 months 63 127 1.29(0.73–2.26) 0.38
12–17 months 55 105 0.65(0.41–1.02) 0.06*
18-23 months 33 94 1
Educational status of mothers No formal education 94 213 0.87(0..59–1.31) 0.51
Formal education 57 113 1
Educational status of fathers No formal education 78 160 1.13(0.77–1.67) 0.53
Formal education 71 165 1
Mothers occupation Unemployed 149 310 3.84(0.87–16.94) 0.07*
Government/private employee 2 16 1
Fathers occupation Unemployed 145 309 1.76(0.57–5.39) 0.32
Government/private employee 4 15 1
Total number of family size within households Greater than 5 86 172 1.18(0.80–1.74) 0.39
Less than or equal to 5 65 154 1
Number of under five children within household More than one child 111 129 4.24(2.77–6.477) 0.001*
One child 40 197 1
Wealth Low 66 135 1.23(0.80–1.88) 0.34
Middle 27 45 1.51(086–2.66) 0.15*
High 58 146 1
Introduction time of complementary feeding Earlier than 6 months 69 154 0.94(0.64–1.38) 0.75
Just at 6 months 82 172 1
Breast feeding practice of mothers No 38 75 1.14(0.72–1.79) 0.58
Yes 102 229 1
Source of drinking water Public and other sources 147 292 4.28(1.49–12.29) 0.04*
Piped inside compound 4 34 1
Toilet No facility/bush/field 1 11 0.19(0.02–1.49) 0.11*
Have latrine 150 315 1
Having Diarrhoea Yes 50 113 1.04(0.57–1.88) 0.89
No 23 50 1
Having Malaria Yes 7 14 1.08(0.43–2.74) 0.87
No 144 312 1
Dietary diversity score Poor 110 203 1.63(1.06–2.48) 0.02*
Good 41 123 1
Growth monitoring and promotion service utilization No 144 304 1.49(0.62–3.56) 0.37
Yes 7 22 1
Anemia Anemic 45 184 3.05(2.02–4.61) 0.001*
Not anemic 106 326 1
*variables with p < 0.25
Malako et al. BMC Nutrition (2019) 5:3 Page 7 of 11

Table 3 Bivariate analysis that shows independent variables of anemia among children in Damot Sore district, Southern Ethiopia,
from March to April 2017
Variables Anemia status COR (95% C.I.) p
Anemic Not anemic
Characteristics Categories
Sex of the children Male 124 119 0.92(0.64–1.32) 0.67
Female 124 110 1
Age of the mother 15–24 years 44 40 1.30(0.75–2.26) 0.34
25–34 years 145 119 1.44(0.95–2.20) 0.09*
35-49 years 59 70 1
Age of the child 6–11 months 105 85 1.72((1.09–2.72) 0.19*
12-17 months 90 70 1.79(1.12–2.87) 0.02*
18-23 months 53 74 1
Educational status of mother No formal education 166 141 1.26(0.87–1.84) 0.22*
Formal education 82 88 1
Educational status of father No formal education 126 112 1.09(0.75–1.56) 0.65
Formal education 120 116 1
Mother’s occupation Unemployed 241 218 1.74(0.66–4.56) 0.26
Government/private employee 7 11 1
Father’s occupation Unemployed 243 211 6.14(1.76–21.37) 0.01*
Government/private employee 3 16 1
Total number of family size within household Greater than 5 134 124 0.99(0.69–1.43) 0.98
Less than or equal to 5 114 105 1
Number of under five children within household More than one child 137 103 1.51(1.05–2.17) 0.03*
One child 111 126 1
Wealth Low 103 98 0.99(0.67–1.46) 0.96
Middle 40 32 1.18(0.68–2.02) 0.55
High 105 99 1
Introduction time of complementary feeding Earlier than 6 months 142 81 2.45(1.69–3.54) 0.001*
Just at 6 months 106 148 1
Breast feeding practice of mother No 80 33 2.99(1.89–4.74) 0.001*
Yes 148 183 1
Source of drinking water Unprotected well 179 172 1.84(0.90–3.75) 0.09*
Protected well/spring 56 34 2.91(1.31–6.50) 0.01*
Piped inside compound 13 23 1
Toilet No facility/bush/field 9 3 2.84(0.76–10.61) 0.12*
Have latrine 239 226 1
Utilization of insecticide treated bed net (ITN) No 24 21 1.08(0.58–1.99) 0.81
Yes 208 196 1
Having diarrhoea Yes 97 66 0.97(0.55–1.70) 0.91
No 44 29 1
Having malaria Yes 10 11 0.83(0.34–1.99) 0.68
No 238 218 1
Dietary diversity score Poor 190 123 2.82(1.90–4.18) 0.001*
Good 58 106 1
Malako et al. BMC Nutrition (2019) 5:3 Page 8 of 11

Table 3 Bivariate analysis that shows independent variables of anemia among children in Damot Sore district, Southern Ethiopia,
from March to April 2017 (Continued)
Variables Anemia status COR (95% C.I.) p
Anemic Not anemic
Characteristics Categories
Growth monitoring and promotion service utilization No 239 209 2.54(1.13–5.70) 0.02*
Yes 9 20 1
Stunting Stunted(<-2SD) 106 45 3.05(2.02–4.60) 0.001*
Not stunted (≥-2SD) 142 184 1
*variables with p < 0.25

Independent variables associated with anemia after Children who drink water from unprotected well have
adjusting for other variables higher risk of being stunted than their counterparts who
As demonstrated in Table 5, early initiation of comple- drink tap water. This is accordant with study conducted
mentary feeding (AOR = 2.96, 95% CI: 1.23–4.85), poor in different parts of Ethiopia [18–20]. This might occur
dietary diversity (AOR = 2.95, 95% CI: 1.78–4.91), poor as a result of utilization of unimproved drinking water
breast feeding practice (AOR = 2.94, 95% CI: 1.63–5.32) sources and poor sanitation which are directly linked
and stunting (AOR = 3.65, 95% CI: 2.15–6.19) were with chronic childhood growth retardation.
factors associated with anemia in multivariable logistic This study shows that children living in households hav-
regression (Table 5). ing more than one under-five aged children was more
stunted as opposed to households with a child less than 5
years of age. This in agreement with a study conducted in
Discussion Eastern Ethiopia [21], Ethiopian Somali region [22],
This study indicated that out of 477 sampled children Mozambique [23], Kenya [24] and Ghana [25]. Under-five
aged 6–23 months old, 31.7% were stunted and 52% children living in households with many siblings of same
were anemic, which could be described as severe public age category in a low-income setting were subjected to in-
health challenge according to the WHO criteria [13]. creased competition for resources which results in major
This study investigated that, the magnitude of stunting child health constraints such as stunting and nutritional
in our study is nearly same as a study conducted in Shey deficiencies [26].
Bench District, southwest Ethiopia (33.3%) [14], but According to this study, the prevalence of anemia is
much lower than studies conducted in Dabat District higher than the EDHS 2016 report of SNNPR under 5 years
(58.1%) [15] and East Belesa District (57.7%) [16] north of age [27] and much lower than studies conducted in
west Ethiopia respectively and Hosanna town, southern northern (66.6%) [8] and eastern (53.7%) [7] parts of
Ethiopia (35.4%) [17] and EDHS-2016 report for SNNPR Ethiopia, Cameron (66.7%), Sudan (86%) and Uganda
among children 6–59 months was 38.6% [5]. However, (58.8%) [28–30] respectively. This might be attributed to
the result of this study was much higher than a study seasonal food shortage since data were collected in spring
conducted in Kemba District southern Ethiopia in which which is a sunny season characterized by poor consump-
18.7% children were stunted [6]. This might be due to in- tion of diversified foods and also due to the change made
appropriate infant and young children feeding practice such by the existing public health interventions, provision of
as non-diversified diet and inconsistent breast feeding. health information through health extension workers.

Table 4 Multivariable logistic regression analysis of factors which have statically significant association with stunting, in Damot Sore
district, Southern Ethiopia, from March to April 2017
Associated factors Stunting status COR (95% C.I.) AOR (95% C.I.)
Stunted Not stunted
Number of under five children within household More than one child 111 129 4.18(2.67–6.57) 4.18(2.65–6.57)*
One child 40 197 1 1
Source of drinking water Public and other sources 147 292 4.28(1.49–12.29) 4.08(1.33–12.54)
Piped inside compound 4 34 1 1
Anemia Anemic 45 184 2.9(2.02–4.61) 3.13(2.00–4.92)*
Not anemic 106 326 1 1
p < 0.001 **Crude odds ratio with 95% confidence interval ***Adjusted odds ratio with 95% confidence interval
*
Malako et al. BMC Nutrition (2019) 5:3 Page 9 of 11

Table 5 Multivariable logistic regression analysis of factors which have statically significant association with anemia, in Damot Sore
district, Southern Ethiopia, 2017
Associated factors Anemia status COR** AOR***
(95% C.I.) (95% C.I.)
Anemic Not anemic
Dietary diversity score low 190 123 2.82(1.90–4.18)* 2.95(1.78-4.91)*
high 58 106 1
Introduction time Earlier than 6 months of age 142 81 2.45(1.69–3.54) 2.96(4.85)
of complementary
feeding Just at 6 months of age 106 148 1

Breast feeding No 80 33 2.99(1.89–4.74) 2.94(1.63–5.32)

Yes 148 183 1
LAZ <2SD 106 45 3.05(2.02–4.60) 3.65(2.15–6.19)
Normal 142 184 1
p < 0.001 **Crude odds ratio with 95% confidence interval
* ***
Adjusted odds ratio with 95% confidence interval

Children exposed to lower dietary diversity were 2.95 be achieved under the NNP, will be implemented by
times more anemic as compared to their counterparts multi-sectors and on a progress [38]. Implementation of
exposed to a higher dietary diversity. This is in line with this study is, to update the level of stunting and anemia in
a study conducted in Wag-Himra, northern Ethiopia, in this area which will help respecting government offices
which poor micronutrient bioavailability related with (Ministry of health, agriculture, education, etc.), as an in-
anemia was observed [31]. This could be due to seasonal put for stimulating its efforts to achieve its plan of im-
unavailability of citric fruits which enhances iron absorp- proving the productivity of individuals and national GDP.
tion and the socio-economic barriers to provide animal It will also uses as an input to for Growth and Trans-
source foods such as meat. formation Plan GTP-2 (2016–2020), which were targeted
The finding of this study observed that, children who to reduce nutritional problems, through the way it will
started complementary feeding earlier than 6 months contribute to the achievement of sustainable develop-
were 2.96 times more likely to develop anemia than ment goals.
children who start at 6 months. On the contrary, a study
conducted in Nepal [32] and a systematic review [33] re- Anemia and stunting linkage
vealed that early introduction of complementary foods This study suggested that childhood growth retardation
had improved hemoglobin concentrations of children. strongly correlates with anemia in children less than 5
This study is consistent with a study conducted in north- years of age.
ern Ethiopia [8], Lebanon [34], Brazil [35] and China [36]. This relationship could be ascribed significantly to
Which reports that early introduction of solid or liquid anemia and stunting as one of the major outcomes of
foods is related with childhood anemia. Early exposure chronic nutritional deficiencies and hemoglobin concen-
of infants before 6 months of age increases the risks of tration is used for measurement of child growth and
infections and mal-absorption. This might be due to lack long term deficiency led synergic effect [1, 7].
of knowledge about adequacy of excusive breast feeding
alone to infants; and thus, they introduce at least cow milk Limitation of the study
earlier than 6 months. We encounter a number of limitations: because it is a
Government of Ethiopia engaged in many actions to cross-sectional study, casual inference cannot be made
tackle nutritional problems, among them social protec- and also it did not show which preceded, whether out-
tions, national nutrition program, community based nutri- comes or associated factors. Parasite investigation was
tion, micronutrient supplementations, Seqota declarations not done.
and other strategies were used but the problems are still
at their climax [4, 5]. Conclusion
Ghana has a history of implementing integrated anemia This study revealed higher level of stunting and anemia
control programs and reduced prevalence of anemia among children aged 6–23 months than WHO (world
though multi-sectoral collaboration, home fortification of health organization) criteria of public health importance.
foods with multiple micronutrient powders for children Sustainable promotion of diversified diet, optimal com-
6–23 months, simultaneously with malaria prevention plementary feeding, optimal and complementary breast
[37]. Similarly, to reduce stunting ‘Seqota’ Declaration is a feeding practices, improving sanitation infrastructure are
special commitment of government of Ethiopia which will measures needed to tackle these severe public health
Malako et al. BMC Nutrition (2019) 5:3 Page 10 of 11

challenges. Households with more than one under-five Competing interests

children and unsafe source of drinking water and anemia This study is free of any competing financial and non-financial interests as
per author’s declaration.
were factors significantly associated with stunting. On
the other hand, early initiation of complementary feed-
Publisher’s Note
ing, poor dietary diversity, poor breast feeding practice Springer Nature remains neutral with regard to jurisdictional claims in
and stunting were significantly associated with anemia. published maps and institutional affiliations.
Behavioral change communication on sustainable pro-
Author details
motion of diversified diet, optimal and complementary 1
World Vision Ethiopia, Jimma area cluster office, Gewata area development
breast feeding practices and sanitation infrastructure are program, Jimma, Ethiopia. 2Social Medicine and Global Health, Department
measures needed to tackle these severe public health of Clinical Sciences, Malmo, Lund University, Lund, Sweden. 3Health Sciences
and Medicine College, Wolaita Sodo University, Wolaita Sodo, Ethiopia.
challenges. Strengthening integration of nutrition inter- 4
School of public health, Dilla University, Dilla, Ethiopia. 5School of Public
vention activities between and within the existing health Health and Medical Sciences, Jimma University, Jimma, Ethiopia.
facilities and the community on maternal, newborn and
Received: 4 August 2018 Accepted: 20 December 2018
child health services. Multiple micronutrient powders
(sprinkles) should be initiated by partners and longitu-
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